Bipolar II disorder often missed

ALL patients with clinical depression should be screened for bipolar disorder because the condition is often misdiagnosed and mistreated, according to mental health experts.

The comments were made in response to two articles in the latest MJA, which reflect on the case of Charmaine Dragun, a 29-year-old TV newsreader who suicided off The Gap in Sydney in late 2007. A coronial inquest identified that a likely contributor to her suicide was the failure of several health practitioners including GPs, psychologists and psychiatrists to diagnose bipolar II disorder.

Professor Gordon Parker, a psychiatrist and executive director of the Black Dog Institute, wrote that the Dragun case indicated the need for enhanced awareness of bipolar II disorder among health practitioners. (1)

He told MJA InSight that about 20% of psychiatrists “don’t believe” in bipolar II disorder, despite its high suicide rate.

Bipolar II disorder is not as symptomatically severe as bipolar I, and involves episodes of non-psychotic hypomania alternating with melancholic depression.

Professor Parker said the missed diagnosis at the centre of the Dragun case was sadly not exceptional.

“I hear this story a few times a week in new patients. I’ve just seen two people today with the same story. In both cases the interval from onset of symptoms to being referred to us with possible bipolar was about 10 years.”

Professor Parker said that, as an experienced psychiatrist, he believed diagnosing bipolar II disorder was not difficult or time consuming.

He suggested that GPs or psychologists should inquire about mood swings in patients with depression by asking if they had experienced times when they were very energised or wired, spending more money or not needing to sleep.

If people with depression did report these energised moods, Professor Parker said doctors who were not experienced in diagnosing bipolar II could suggest that patients take the Black Dog Institute’s online self-test.

“The test has an 80% level of confidence, and [each month] about 50 000 people do it”, he said.

Associate Professor Greg Murray, head of psychological sciences and statistics at Swinburne University, said identifying bipolar II could be difficult because people tend to present to a health practitioner when in a depressed phase.

“Their depressed mood may make it impossible for them to recall times when they were not depressed.” He said there was a fine line between hypomania and “a really good weekend”.

Professor Murray and Professor Parker emphasised that people with bipolar II disorder generally had melancholic depression, characterised by symptoms such as psychomotor disturbance, anhedonia, and diurnal mood variation.

“If the person sitting in front of you has depression with a heavy biological flavour it’s a cue to hunt for evidence of bipolar disorder”, Professor Murray said.

Professor Parker and Professor Murray agreed that patients with bipolar II are best managed using a team approach.

“GPs who are educated in managing bipolar II may want to manage it — that’s fantastic. If not, my advice is to refer the patient to a psychiatrist who is experienced in bipolar II to clarify the diagnosis and get the patient’s mood swings under control. Then a collaborative endeavour with a psychologist, running a ‘stay well’ plan, is the best approach”, Professor Parker said.

An accompanying editorial in the MJA explained that doctors have an obligation to refer patients when another practitioner is better placed to advance the patients’ interests. (2)

The consequences of misdiagnosing bipolar II disorder as unipolar depression were severe.

Professor Parker said people with bipolar II disorder were more likely to require mood stabilisers than antidepressants. There was a lot of evidence that antidepressants could worsen the bipolar disorder by inducing more rapid cycling of symptoms and increasing the frequency of episodes, he added.

13 thoughts on “Bipolar II disorder often missed”

I’m sure the Black Dog checklist has high sensitivity but am not sure about the specificity. Brief mood swings don’t only occur with BPAD II; they also occur due to recreational drug use and personality disorder, both of which are also associated with depression. Yet, the test makes no mention of drug use & doesn’t establish the duration of the ‘highs’, or whether these are precipitated by external events. A brief high lasting a few hours ppted by an external event is more suggestive of a personality disorder. In addition recreational drug use should always be screened for. I can forecast a deluge of referrals of people demanding mood stabilisers following this. These drugs are not ‘smarties’ – they require frequent blood tests, have their own risks & are a long-term commitment.

Thank you for your wise words, Steve. We are all too ready to see the solution to life’s emotional challenges in the “right” pill bottle. Many people who present to health services are given a diagnosis of depression, for which they are prescribed anti-depressants; or anxiety, for which they are prescribed anxiolytics, when the true diagnosis is “unexpressed painful feeling for which the treatment is to express it” (Malan, 1979, p. 3). Psychodynamic therapy …enables the person to face what s/he really feels, to realise that it is not as painful or as dangerous as feared, to work through it in a [therapeutic] relationship, and finally to be able to make use of real feelings within relationships in a constructive way” (p. 30). The aim of this emotional learning should be permanent, in that adaptive behaviours have replaced maladaptive attitudes and behaviours, and that these adaptive attitudes and behaviours can be generalised to new people and new situations in such a way that the learning becomes self-reinforcing. Perhaps we should also be screening for unexpressed painful feeling and then allowing our patients to express it.

It would be very interesting to do a survey of psychiatrists as to whether “20% don’t believe in bipolar-II”. I suspect the figure is greater and the issue is more complex.
Similarly the poll question is too simplistic. Virtually everyone should answer “yes” – of course asking and screening for mania/hypomania is vital in anyone who is depressed. The question, in the context of the article, seems designed to support the premise of broad spectrum bipolar.
The controversial area is what constitutes hypomania as part of a bipolar illness versus what constitutes reactive attempts by people struggling with stress and depressive symptoms.
The concept of “manic defence” still has salience a century after it was described. Personality traits and disorders have some people use denial and reaction formation to cope at times. This is particularly true where there are histories of trauma and abuse. This is part of what it means to be histrionic or borderline in personality dynamics.
Obsessional and perfectionistic types can overwork and become increasingly obsessive when stressed. Sleep deprivation can have a mood elevating effect.
Some bipolar-II is undoubtedly mild versions of bipolar-I but the problem with “bipolar-II” is that it is applied too widely and often leads to a reductionist view that neglects trauma, personality and lifestyle factors including substance use.
What’s more “mood stabilizers” be they anticonvulsant or antipsychotics have a nasty array of side-effects. Their use should be reserved for unequivocal cases of bipolar disorder.

In my 35 years of private practice in psychiatry I have found that undiagnosed bipolar spectrum disorder is the most common reason people present with problems about their lives having been a shambles for years. While I agree with Steve’s comments generally, I think personality disorders are over-diagnosed especially in the public sector. Checking the family history for symptom patterns suggestive of bipolar spectrum disorder is often a useful clue in weighing the significance of transient “highs”.

A difficult situation for GPs, as no-one wants to risk suicide by a patient. However it is also true that unexpressed emotions and real life situations should not be simply suppressed pharmacologically. Quetiapine and lithium are both serious and nonspecific drugs. It is astounding how little research has been done to find the real molecular cause(s) of bipolar affective disorder. Some of the Aust government’s increased funding should be going into sorting out the underlying pathogenesis and not just filling out forms.

“The drug companies learned a while back that the best way to sell drugs was to sell diagnoses… selling the diagnosis is a way of opening up the new market. New diagnoses are as dangerous as new drugs, at least in psychiatry.” Dr Allen Frances, chair of DSM IV task force – 2011.

Dr Gordon Parker is executive director of the Black Dog Institute. From their website: “New drugs have brought great advances in recent years in the treatment of the mood disorders. The Black Dog Institute is at the forefront of research into therapeutic benefits of drug treatments, and works closely with pharmaceutical companies.”

To Shyamala Hiriyanna
Vote for a state and federal member who promises to redress the imbalance between what is paid by the pseudo-insurance company Medicare and the true cost of the services rendered, then a significant number of psychiatrists will bulk bill.
The relative value study demonstrated as a fact that Medicare rebates were on the average only about half what is the true value for doctors’ work.
As for the accusations of vested interest, think about the history of research. Used to be done in well-funded independent university departments or foundations. Bean counters in power at state and federal level have starved this service. In Australia, reform means going back to the Dark Ages.

You could easily write an article: “Bipolar-II often overdiagnosed” and find psychiatrists who could strongly argue the case for that title. You could run a poll saying “should all patients with mood lability be screened for their developmental and life histories and contextual stressors, personality dynamics and substance use histories – in addition to symptoms possibly suggestive of mania or hypomania?”

Maybe some are overdiagnosed, yes antipsychotics have side effects – but in some cases can lead to enormous relief and should be considered as a option without judgement. Stigma from society is bad enough let alone stigma from the psychiatric profession as evidenced from the conversation above. Let me tell you about my own experience: A few years ago I had a many months long depressive episode that just was’t getting better – it wasn’t until I went to a second psychiatrist who made a diagnosis of bipolar 2 and prescribed a very small dose of lithium that i got better – quit dramatically. This small dose of lithium led to such a dramatic improvement so quickly I would not now dream of not being on it. I do not, under any circumstances wish to experience depression again it was hell on earth. A more open mind from members of the profession would go a long way to helping many people and reducing societal stigma too.

I’m in my mid 50’s and have been taking MAOs, SSRIs and finally SNRIs for in excess of 20 years. Its only been recently, following (uncharacteristic) and manic behaviour patterns after long term treatment with mirtazapine (remeron) that I have recognised my own behaviour as classic BP2. The mirtazapine, now thankfully discontinued, had been responsible for major marital stresses arising from an overwhelming sense of entitlement coupled with insomnia and hypersexuality. I now recognise that I have been consistently misdiagnosed as having, first mild and later, severe depression and that the latest medication has taken me to the brink. There must be hundreds, perhaps thousands like me out there, I’m just an average guy trying to earn a living and have a stable marriage and family.

I was diagnosed with bipolar disorder more than 20 years ago. However that diagnosis has never sat well on a scientiific basis. Prior to diagnosos I had suffered many years of depression and never experienced any manic or hypomanic episodes. Following the commencement of anti-depressants I “normalised” and then experienced mania. Drug induced psychosis is a well documented phenomenum in the world of recreational drugs. I was depressed and placed on medicaltion to elevate my mood and it worked.. it also overshot the “desired’ response. I was merely depressed until the medical community got their hands on me.

Labelling a person as biploar because a doctor is unwilling to accept a diagnosis of iatrogenic drug-induced psychosis results in profound stigma and economic disadvantage.

I’ve recently diagnosed as being bipolar 2, before that I was thought to have major depressive disorder. Over 2 – 3 years, I saw 4 psychiatrists who ruled bipolar out because the sessions never really went in depth. The answers to questions asked were almost normal but didn’t factor in that I had a strict upbringing which tempered most of my behaviour. To give examples: I have been in a committed relationship with my fiance who was my first boyfriend, if they had asked further they would have found out I got pregnant to him at 17, nearly cheated on him with my 2IC and ended up in an open relationship for 6 months which upon reflection showed many instances of poor judgement. None asked me about spending sprees until I brought up that I was feeling guilty because for months I’d been able to abstain from frivolous spending but recently felt the urge to spend to the detriment of my partner. These were relatively frequent occurances, previously they hadn’t bothered me much because I was working and paying for the sprees myself. I had numerous times mentioned trouble sleeping at night, no one asked if I had days on end in which I didn’t sleep. I don’t sleep or sleep for only 2 – 4 hours within a 3 – 5 day period when I’m feeling wired during which I run around getting a multitude of things done, then crash for a month. For 2 – 3 years I was treated for depression. I would usually end up reporting doing well for a few weeks and then go downhill for about a month and a half. Although the diagnosis scares me a little because I don’t know how much success has been had with treatment, I’m more optimistic that at least we are trying to treat the right thing now.